(A)(B) Except as otherwise
provided in this rule, a managed care
plan
organization(MCP)
(MCO) and the single pharmacy benefit manager
(SPBM) must ensure members have access to all medically necessary
services
, as applicable, covered by Ohio medicaid
under the state plan.
Specific coverage provisions
for "MyCare Ohio" plans as defined in rule 5160-58-01 of the Administrative
Code are described in Chapter 5160-58 of the Administrative Code. The
MCP
MCO and
SPBM must ensure:
(1) Services are
sufficient in amount, duration, or
and scope to reasonably be expected to achieve
the purpose for which the services are furnished
provided;
(2) The amount, duration,
or
and scope
of a required service is not arbitrarily denied or reduced solely because of
the diagnosis, type of illness, or condition;
(3) Prior authorization is available for
services on which an MCP
the MCO or the SPBM has placed a pre-identified
limitation to ensure the limitation may be exceeded when medically necessary,
unless the MCP
MCO
or SPBM's
's limitation is also a
limitation for fee-for-service medicaid coverage;
(4) Coverage decisions are based on the
coverage and medical necessity criteria published in agency 5160 of the
Administrative Code and practice guidelines specified in rule
5160-26-05.1 of the
Administrative Code; and
(5) If a
member is unable to obtain medically necessary services offered by medicaid
from a
an
MCP
MCO or
SPBM
panel
network provider, the MCP
MCO or SPBM must
adequately and timely cover the services out of panel
network, until
the MCP
MCO or
SPBM is able to provide the services from a panel
network
provider.
(E)
Services covered
by an MCO.
(d)(1) The
MCP
MCO must
cover annual physical examinations for adults.
(E)(2) At the request of
the member, an MCP
the MCO must provide for a second opinion from a
qualified health care professional within the panel
MCO's network.
If such a qualified health care professional is not available within the
MCP
MCO's
panel
network,
the MCP
MCO
must arrange for the member to obtain a second opinion outside the
panel
MCO's
network, at no cost to the member.
(F)(3)
The
MCP
MCO
must ensure emergency services as defined in rule
5160-26-01 of the Administrative
Code are provided and covered twenty-four hours a day, seven days a week. At a
minimum, such services must be provided and reimbursed in accordance with the
following:
(1)(a) The
MCP
MCO cannot
deny payment for treatment obtained when a member had an emergency medical
condition
, as defined in rule
5160-26-01 of the Administrative
Code.
(2)(b) The
MCP
MCO cannot
limit what constitutes an emergency medical condition on the basis of lists of
diagnoses or symptoms.
(3)(c) The
MCP
MCO must
cover all emergency services without requiring prior authorization.
(4)(d)
The MCP
MCO
must cover medicaid-covered services related to the member's emergency medical
condition when the member is instructed to go to an emergency facility by a
representative of the MCP
MCO, including but not limited to, the member's primary care provider (PCP) or the
MCP's
MCO's
twenty-four-hour toll-free phone number.
(5)(e)
The MCP
MCO
cannot deny payment of emergency services based on the treating provider,
hospital, or fiscal representative not notifying the member's PCP of the visit.
(6)(f)
For the purposes of this paragraph, "non-contracting
provider of emergency services" means any person, institution, or entity who
does not contract with the MCP but provides emergency services to an MCP
member, regardless of whether that provider has a medicaid provider agreement
with the ODM. An MCP
The MCO must cover
emergency services as defined in rule
5160-26-01 of the Administrative
Code when the services are delivered by a non-contracting provider of emergency
services and claims for these services cannot be denied regardless of whether
the services meet an emergency medical condition as defined in rule
5160-26-01 of the Administrative
Code. Such services must be reimbursed by the
MCP
MCO at the lesser
of billed charges or one hundred per cent of the Ohio medicaid program
reimbursement rate (less any payments for indirect costs of medical education
and direct costs of graduate medical education that is included in the Ohio
medicaid program reimbursement rate) in effect for the date of service. If an
inpatient admission results, the
MCP
MCO is required to reimburse at this rate only until
the member can be transferred to a provider designated by the
MCP
MCO.
Pursuant to section
5167.10 of the Revised Code, the
MCP
MCO shall
not compensate a hospital for inpatient capital costs in an amount that exceeds
the maximum rate established by ODM.
(7)(g) The
MCP
MCO must
cover emergency services until the member is stabilized and can be safely
discharged or transferred.
(8)(h) The
MCP
MCO must
adhere to the judgment of the attending provider when requesting a member's
transfer to another facility or discharge. MCPs
the MCO may
establish arrangements with hospitals whereby the MCP
MCO may designate
one of its contracting providers to assume the attending provider's
responsibilities to stabilize, treat, and
transfer the member.
(9)(i) A member who has
had an emergency medical condition may not be held liable for payment of any
subsequent screening and treatment needed to diagnose the specific condition or
stabilize the member.
(G)(4) The
MCP
MCO must
establish, in writing, the process and procedures for the submission of claims
for services delivered by non-contracting providers, including non-contracting
providers of emergency services.
as described in paragraph (E)(6) of this
rule. Such information must be made available upon request to
non-contracting providers, including non-contracting providers of emergency
services. an MCP
The
MCO shall not establish claims filing and processing procedures for
non-contracting providers, including non-contracting providers of emergency
services, that are more stringent than those established for their contracting
providers.
(H)(5) The
MCP
MCO must
ensure post-stabilization care services as defined in rule
5160-26-01 of the Administrative
Code are provided and covered twenty-four hours a day, seven days a week.
(1)(a)
The MCP
MCO
must designate a telephone line to receive provider requests for coverage of
post-stabilization care services. The line must be available twenty-four hours
a day. an MCP
the
MCO must document that the telephone number and process for obtaining
authorization has been provided to each emergency facility in the service area.
The MCP
MCO
must maintain a record of any request for coverage of post-stabilization care
services that is denied including, at a minimum, the time of the provider's
request and the time the MCP
MCO communicated the decision in writing to the
provider.
(2)(b) At a minimum,
post-stabilization care services must be provided and reimbursed in accordance
with the following:
(a)(i) The
MCP
MCO must
cover services obtained within or outside the MCP's
panel
MCO's network that are
pre-approved in writing to the requesting provider by
a plan
an MCO
provider or other MCP
MCO representative.
(b)(ii) The
MCP
MCO must
cover services obtained within or outside the MCP's
panel
MCO's network that are not
pre-approved by a plan
an MCO provider or other
MCP
MCO
representative but are administered to maintain the member's stabilized
condition within one hour of a request to the MCP
MCO for
pre-approval of further post-stabilization care services.
(c)(iii)
The
MCP
MCO
must cover services obtained within or outside the
MCP's panel
MCO's
network that are not pre-approved by
a
plan
an MCO provider or other
MCP
MCO
representative but are administered to maintain, improve
, or resolve the member's stabilized condition if:
(i)(a)
The MCP
MCO
fails to respond within one hour to a provider request for authorization to
provide such services.
(ii)(b)
The MCP cannot be contacted.
The provider has documented an attempt to contact the MCO to
request authorization, but the MCO can not be contacted.
(iii)(c)
The MCP's
MCO's representative and treating provider cannot
reach an agreement concerning the member's care and a plan
an MCO
provider is not available for consultation. In this situation, the
MCP
MCO must
give the treating provider the opportunity to consult with
a plan
an MCO
provider and the treating provider may continue with care until
a plan
an MCO
provider is reached or one of the criteria specified in paragraph
(E)(5)(c)(G)(3) of this rule is met.
(3)(c) The
MCP's
MCO's
financial responsibility for post-stabilization care services not pre-approved
ends when:
(A)(i)
a plan
an MCO
provider with privileges at the treating hospital assumes responsibility for
the member's care;
(B)(ii)
a plan
an MCO
provider assumes responsibility for the member's care through
transfer;
(c)(iii) An
MCP
MCO
representative and the treating provider reach an agreement concerning the
member's care; or
(d)(iv) The member is
discharged.
(I) MCP responsibilities for payment
of other services.
(1)(6)
When an
MCP
MCO member has a nursing facility (NF) stay, the
MCP
MCO is
responsible for payment of medically necessary NF services
, until
the member is
discharge
d or until the member is disenrolled in
accordance with the processes set forth in rule
5160-26-02.1 of the
Administrative Code.
(2)(7) The
MCP
MCO is not
responsible for payment of home and community-based services (HCBS) provided to
a member who is enrolled in an HCBS waiver program administered by ODM, the
Ohio department of aging (ODA), or the Ohio department of developmental
disabilities (DODD).
(3)(8)
MCP
MCO
members are permitted to self-refer to Title X services provided by any
qualified family planning provider (QFPP). The MCP
MCO is responsible
for payment of claims for Title X services delivered by QFPPs not contracting
with the MCP
MCO at the lesser of one hundred per cent of the Ohio
medicaid program fee-for-service reimbursement rate or billed charges, in effect for the date of service.
(4)(9)
The MCP
MCO
must permit members to self-refer to any women's health specialist within the
MCP's panel
MCO's
network for covered care necessary to provide women's routine and
preventive health care services. This is in addition to the member's designated
PCP if that PCP is not a women's health specialist.
(5)(10) The
MCP
MCO must
ensure access to covered services provided by all federally qualified health
centers (FQHCs) and rural health clinics (RHCs).
(6)(11) Where available,
the MCP
MCO
must ensure access to covered services provided by a certified nurse
practitioner.
(7)(12) ODM may approve an
MCP's
MCO's
members to be referred to certain
MCP
MCO non-contracting hospitals, as specified in rule
5160-26-11 of the Administrative
Code, for medicaid-covered non-emergency hospital services. When ODM permits
such authorization, ODM will notify the
MCP
MCO and the
MCP
MCO
non-contracting hospital of the terms and conditions, including the duration,
of the approval and the
MCP
MCO must reimburse
the
MCP
MCO
non-contracting hospital at one hundred per cent of the current Ohio medicaid
program fee-for-service reimbursement rate in effect for the date of service
for all medicaid-covered non-emergency hospital services delivered by the
MCP
MCO
non-contracting hospital. ODM will base its determination of when an
MCP
MCO's
members can be referred to
MCP
MCO non-contracting hospitals pursuant to the
following:
(a) The MCP's
MCO's submission
of a written request to ODM for the approval to refer members to a hospital
that has declined to contract with the MCP
MCO. The request
must document the MCP's
MCO's contracting efforts and why the
MCP
MCO
believes it will be necessary for members to be referred to this
particular hospital; and
(b) ODM consultation with the
MCP
MCO
non-contracting hospital to determine the basis for the hospital's decision to
decline to contract with the MCP
MCO, including but not limited to whether the
MCP's
MCO's
contracting efforts were unreasonable and/or that contracting with the
MCP
MCO would
have adversely impacted the hospital's business.
(8)(13)
Paragraph
(H)(7)
(E)(12) of this rule is not applicable when
an MCP
the MCO
and an
MCP
MCO
non-contracting hospital have mutually agreed
to that
the
non-contracting hospital
will
providing
provide non-emergency hospital services to an
MCP's
MCO's
members. The
MCP
MCO must ensure that such arrangements comply with
rule
5160-26-05 of the Administrative
Code.
(9)(14) The
MCP
MCO is not
responsible for payment of services provided through medicaid school program
(MSP) pursuant to Chapter 5160-35 of the Administrative Code.
an MCP
The MCO
must ensure access to medicaid-covered services for members who are unable to
timely access services or unwilling to access services through MSP providers.
(10) The MCP is not required to
cover services provided to members outside the United States.
(11)(15) When a member is
determined to be no longer eligible for enrollment in an
MCP
MCO during
a stay in an institution for mental disease (IMD), the
MCP
MCO is not
responsible for payment of that IMD stay after the date of disenrollment from
the plan
MCO.
(16)
The MCO must provide two dental cleanings per year to
pregnant members of the eligibility group described in section
5163.06 of the Revised
Code.
(J)(17)
The MCO must cover respite services as described in
rule 5160-26-03.2 of the
Administrative Code."Respite services" are
services that provide short-term, temporary relief to the informal unpaid
caregiver of an individual under the age of twenty-one in order to support and
preserve the primary caregiving relationship. The MCP shall be responsible for
payment for respite services. Respite services can be provided on a planned or
emergency basis. The provider must be awake when the member is awake during the
provision of respite services.
(1) To be eligible for respite
services, the member must:
(a) Reside with his or her informal,
unpaid primary caregiver in a home or an apartment that is not owned, leased or
controlled by a provider of any health-related treatment or support
services;
(b) Not be a foster child, as
defined in Chapter 5101:2-1 of the Administrative Code;
(c) Be under twenty-one years of
age;
(d) Currently be participating in a
care management /coordination arrangement; and
(e) Meet either of the
following:
(i) Have long-term service and
support (LTSS) needs as determined by the MCP through an institutional level of
care determination as set forth in rule 5123:2-8-01, 5160-3-08 or 5160-3-09 of
the Administrative Code, and
(a)
Require skilled nursing or skilled rehabilitation
services at least once per week,
(b)
Be determined eligible for social security income
for children with disabilities or supplemental security income,
(c)
Had a need for at least fourteen hours per week of
home health aide services for at least two consecutive months immediately
preceding the date respite services are requested, and
(d)
The MCP must have determined that the member's
primary caregiver has a need for temporary relief from the care of the member
as a result of the member's LTSS needs, or in order to prevent an inpatient,
institutional or out-of-home stay; or
(ii) Have behavioral health needs as
determined by the MCP through the use of a nationally recognized standardized
functional assessment tool, and
(a)
Be diagnosed with serious emotional disturbance as
described in the appendix to this rule resulting in a functional
impairment,
(b)
Not be exhibiting symptoms or behaviors that
indicate imminent risk of harm to himself or herself or others,
and
(c)
The MCP must have determined that the member's
primary caregiver has a need for temporary relief from the care of the member
as a result of the member's behavioral health needs, either:
(i)
To prevent an inpatient, institutional or
out-of-home stay; or
(ii)
Because the member has a history of inpatient,
institutional or out-of-home stays.
(2) Respite services are limited to
one hundred hours per calendar year per member, however, this may be exceeded
through MCP prior authorization on the basis of medical
necessity.
(3) LTSS respite services must be
provided by individuals employed by medicaid enrolled agency providers that are
either medicare-certified home health agencies pursuant to Chapter 3701-60 of
the Administrative Code, or accredited by the "Joint Commission," the
"Community Health Accreditation Program," or the "Accreditation Commission for
Health Care."
(a) LTSS respite providers must
comply with the criminal records check requirements set forth in rules
5160-45-07 and 5160-45-11 of the Administrative Code.
(b) Before commencing service
delivery, the LTSS provider agency employee must:
(i) Obtain a certificate of
completion of either a competency evaluation program or training and competency
evaluation program approved or conducted by the Ohio department of health under
section 3721.31 of the Revised Code, or the medicare competency evaluation
program for home health aides as specified in 42 C.F.R. 484.36 (October 1,
2019), and
(ii) Obtain and maintain first aid
certification from a class that is not solely internet-based and that includes
hands-on training by a certified first aid instructor and a successful return
demonstration of what was learned in the course.
(c) After commencing service
delivery, the LTSS provider agency employee must:
(i) Maintain evidence of completion
of twelve hours of in-service continuing education within a twelve-month
period, excluding agency and program-specific orientation, and
(ii) Receive supervision from an
Ohio-licensed registered nurse (RN) and meet any additional supervisory
requirements pursuant to the agency's certification or
accreditation.
(4) Behavioral health respite
services must be provided by individuals employed by OhioMHAS-certified and
medicaid enrolled agency providers that are also accredited by the "Joint
Commission," "Council on Accreditation" or "Commission on Accreditation of
Rehabilitation Facilities."
(a) Behavioral health respite
providers must comply with the criminal records check requirements set forth in
rule 5160-43-09 of the Administrative Code when the service is provided in an
HCBS setting.
(b) Before commencing service
delivery, the behavioral health provider agency employee must:
(i) Either be credentialed by the
Ohio counselor, social worker and marriage and family therapist board, the
state of Ohio psychology board, the state of Ohio board of nursing or the state
of Ohio medical board or received training for or education in mental health
competencies and have demonstrated, prior to or within ninety days of hire,
competencies in basic mental health skills along with competencies established
by the agency; and
(ii) Obtain and maintain first aid
certification from a class that is not solely internet-based and that includes
hands-on training by a certified first aid instructor and a successful return
demonstration of what was learned in the course.
(c) After commencing service
delivery, the behavioral health provider agency employee must receive
supervision from an independently licensed behavioral health professional
credentialed by the Ohio counselor, social worker and marriage and family
therapist board, the state of Ohio psychology board, the state of Ohio board of
nursing or the state of Ohio medical board.
(5) Respite services must not be
delivered by the member's "legally responsible family member" as that term is
defined in rule 5160-45-01 of the Administrative Code or the member's foster
caregiver.
(18)
The MCO is not responsible for covering services
described in rule
5160-59-03 of the Administrative
Code for a member enrolled in the OhioRISE plan.
